Many doctors “have outsourced their brains to the pharmaceutical industry”, says University of Cape Town emeritus professor Tim Noakes. Ditto for dietitians who belong to the Association for Dietetics in SA (ADSA). They dismiss the nutritional approach to disease prevention without even reading the literature, he says.

Here, in the second of a two-part Q&A, Noakes looks at why modern medicine has created many “doctors of disease”, not health. He fingers the real medical “criminals”. These are the doctors who, he says, will ultimately prove to be responsible for killing their patients because of their commitment to conventional medical “wisdom”.

These people and organisations have prejudices and conflicts of interest they are reluctant to acknowledge. It’s as if they believe if they don’t acknowledge these conflicts, the conflicts will simply disappear. The Heart Foundation has promoted vegetable oils for the past decade or so without any evidence that they are healthy, and growing evidence that they may be harmful because they increase our intake of inflammation-promoting omega-6 polyunsaturated fats and margarines. Their sources of industrial financial support perhaps make it impossible for them to acknowledge their error. Dr Raal has been a keen advocate of the widespread prescription of cholesterol-lowering drugs that we now know benefit at best one in 100 otherwise healthy patients and extend life by about three days at best.

You call statins the “single most ineffective drug ever invented”. Isn’t that a bit harsh?

The extent to which these drugs cause unpleasant and sometimes perhaps serious side effects is seldom acknowledged. It is difficult for me to understand why anyone would wish to promote the widespread use of such medications when a simple change in diet to a low-carbohydrate diet is likely to be a very much more effective option. But then there is no financial reward for the pharmaceutical industry (and its medical proxies) if patients exchange expensive but largely ineffective medications for a more effective dietary therapy.

You clearly don’t subscribe to the diet-heart hypothesis?

No one has ever proven that “bad cholesterol” in the blood causes heart disease or that a high fat diet is involved. It’s an unproven hypothesis, an assumption based on epidemiology, and destroyed by Nina Teicholz in The Big Fat Surprise and also by the Credit Suisse report on Fat: The New Paradigm. I would like to know from the experts which studies prove this, because Nina and now many others show there aren’t any. The problem we now know is the presence of non alcoholic fatty liver disease (NAFLD) in those with insulin resistance.

It is the fatty liver in NAFLD that overproduces the toxic lipoproteins (small dense LDL particles – not “cholesterol” – associated with high blood insulin, glucose and Apo-B concentrations and low HDL-cholesterol concentrations) that cause arterial disease leading to heart attacks and strokes. NAFLD is caused by sugar and high carbohydrate diets (perhaps worsened by vegetable oils), not by dietary saturated fats. That is, it is carbohydrates not dietary fats that cause damage to the arteries leading to heart attacks and strokes.

Johannesburg cardiologist Dr Anthony Dalby claims all the fat in your ‘Noakes diet’ will end up killing people. Is it possible?

No, because dietary saturated fat is not the cause of heart disease. It is carbohydrates in the diet that have promoted insulin resistance and the development of NAFLD that are the cause of the problem. If the Heart Foundation, the Stellenbosch researchers (authors of a review of the evidence published in PLOS One in 2014), dietitians and others who continue to state categorically that dietary fat is the problem, want to be scientific and credible, they should acknowledge there’s no evidence. Eventually they’ll have to admit they were wrong, and that taking fat out of the diet and replacing it with sugar and carbohydrate has caused the obesity epidemic. The Heart Foundation in particular is accountable; the longer it takes to acknowledge the evidence, the worse the repercussions, including unnecessary deaths, over time.

Prof Derick Raal

Raal says your view of statins is “potentially life-threatening” statement for patients with familial hypercholesterolaemia who’ve had a heart attack or bypass surgery. Dalby calls it “criminal”. Could it be in patients with that genetic predisposition?

No, because I always say that patients who have elevated blood cholesterol concentrations should be properly evaluated for the real causes of heart disease including insulin resistance and NAFLD and placed on the appropriate low-carbohydrate diet. Then if they still need medications they should be fully informed of the risks and benefits of such treatments. Using emotive phrases like “potentially life-threatening” is not scientific and simply scares the patient into accepting what the authoritarian doctor wants the patient to do – for the doctor’s own reasons, including inflated ego and self-importance.

Medicine is changing and the new medicine is patient-centred, not doctor-centred. Doctors who cannot let go and allow patients to make their own decisions based on the totality of evidence have no place in this new medical philosophy. I’d say it’s criminal to prescribe drugs to people who don’t need them especially if there is risk that these drugs may cause harm. It’s also criminal not to provide patients with all the relevant information he or she needs to make an informed decision about choices that will effect their own health.

A dietitian once told me one of her patients developed fatty liver disease after starting your diet. She says the woman probably had a predisposition for the disease, but your diet triggered it. Is that possible?

No. The dietitian clearly doesn’t know that fatty liver disease is caused by excessive dietary carbohydrates, not dietary fat. The latest research shows that fatty liver disease is the real problem that causes the abnormal blood “cholesterol” changes that lead to heart disease and in future the prevention of heart disease will be the territory of hepatologists (liver specialists), not cardiologists.

That isn’t a message cardiologists will be keen to hear. Unless they wake up and brush up on their biochemistry, their medical influence in the prevention of heart disease will disappear. On the other hand it is remarkable how little emphasis cardiologists around the world place on disease prevention, other than the prescription of cholesterol-lowering drugs which the evidence continues to show are a pretty ineffective solution for those who are initially free of heart disease, and especially for women.

Have you ever claimed your LCHF diet cures heart disease?

No. I claim it reverses symptoms of insulin resistance and metabolic syndrome (in those who comply and continue to comply with our rigid eating rules) that increase the risk of chronic disease, including diabetes and heart disease, and perhaps also cancer and dementia. If you have the syndrome, and cut out carbohydrates, you may go into remission, because you reduce all the risk factors, including hypertension, high blood glucose, high blood triglycerides, but more importantly the small dense LDL cholesterol particles in the blood, and inflammation.

Have you ever said your diet is right for everyone – a one-size-fits-all?

I’ve never said that. What I have said is: it will benefit you if you are insulin resistant, and in my view, many people are these days. I also say if you avoid processed foods, focus on fats, and eat real food from the green list (in The Real Meal Revolution), your health will benefit. I’ve never said it any other way. By the way, California has recently announced that 50% of Californians are insulin resistance with diabetes or pre-diabetes. As they say: Today California, tomorrow the World. So if I were in California I would say that at least 50% of the population will benefit from this eating plan.

Why are so many people insulin resistant these days?

Probably an evolutionary adaptation that had biological value – people with the genes were more likely to survive on a diet that comprised mainly fat and protein with little carbohydrate. The genes have always been there. The negative consequences were not expressed until the introduction of high-carbohydrate diets in the last 40 years – foods that are highly processed and laden with sugar. That turned insulin resistance into an epidemic of obesity and diabetes.

Prof Jacques Rossouw

One of your most vocal critics is South African-born epidemiologist Prof Jacques Rossouw, recently retired from the US National Institutes of Health. At the UCT Faculty of Health Sciences Centenary Debate with you in December 2012, he argued in favour of the diet-heart disease hypothesis and statins. Does Rossouw have any points?

This is a man who has spent more than $700 million of American taxpayers’ money in a clinical trial lasting eight years, and proving that cutting fat from the diet had no beneficial effect whatsoever on the health of post-menopausal women (the Women’s Health …)… Nor did it help them to lose weight. So the irony: The researcher whose work is the definitive disproof that the low-fat diet can improve health and prevent heart disease was chosen by the UCT Faculty of Health Sciences to defend the very hypothesis his own $700 million dollar study had already disproven six years earlier. He is also the scientist most frequently invited to South Africa by the Association for Dietetics in South Africa (ADSA) to continue presenting the argument for the (unproven) health benefits of the low fat diet.

Is there any published research to show he got it wrong?

I was the first to show and publish in the SAMJ (November 2013), that Rossouw’s own data showed that women with established heart disease, who reduced their fat intake, were more likely to suffer subsequent heart attacks than women with heart disease who continued their conventional, higher-fat diet. He showed the same for patients with diabetes. Neither he nor anyone else was brave enough to admit to these inconvenient findings. If only a tiny fraction of the money for that low-fat study had been spent on studies of high-fat diets, we wouldn’t be having this debate.

Why do you think that is?

When you spend that magnitude of other people’s money, and disprove your own deeply held dogmas, you should admit: “I was wrong. Reducing fat in your diet may make you worse.” It takes courage to say that. Instead, he continues to spin the opposite. That’s not science. It’s religion. But had he tested the low carbohydrate diet, those with insulin resistance or diabetes would have benefitted dramatically and his finding would have been revolutionary. Instead the prestige of proving the value of low carbohydrate diets for health will belong to others in the future.

Do you ever say that the ‘Tim Noakes diet’ cures cancer?

No. I do say research shows that cancer is a carbohydrate-driven disease. Cancer cells are proven to be utterly glucose dependent. Some cancers can get their glucose from protein, but cancer cells have to get glucose from somewhere; they cannot get their energy from the oxidation of fat.

Is that just your opinion?

No. It’s in the work of (German physiologist and medical doctor) Otto Warburg who won the 1931 Nobel Prize of physiology and medicine. We just kind of forgot that, because cancer research went in a completely different direction.

What direction is that?

We invested billions of dollars into drugs to kill cancer cells. Scientists who got it wrong have driven the research, but won’t admit it. They plod along, trying to cure cancer according to a model that clearly doesn’t work.

Is there support for your view that the orthodox model on which cancer treatment is based doesn’t work?

Dr Craig Thompson

Yes, world authorities, including Dr Craig Thompson of the Memorial Sloan Kettering Cancer Centre. In a YouTube video of a 2011 talk on cancer, he says in effect: “If I encourage you to eat a high-fat diet, it won’t change your cancer risk one iota. If I encourage you to eat carbohydrates, it will.”

What’s the future of cancer research?

Scientists must realise cancer is a nutritional, carbohydrate-dependent disease, and need to work out ways to starve cancer cells of glucose. The person who does that will win the Nobel Prize. And deservedly so. For he or she will have to stand up to vilification and humiliation that will make my experience look like childs’ play.

What’s really behind attacks on you?

It goes to the core of medical practice, and threatens massive industries. We are being manipulated and controlled – by governments, by the pharmaceutical industry, by the food industry – to believe one particular dietary approach that simply doesn’t work and is the cause of our growing ill-health as humans. The current pharmacological model has taken over medicine. It encourages future patients to eat foods that will make them ill, and only then treats them with one or other of its array of powerful chemicals. It’s a model that clearly doesn’t work, because it doesn’t try to understand what first caused a specific disease in a specific patient. For that has been the way in which we have been taught medicine for at least the last century – your duty as a doctor is to try to understand what causes this disease in this particular patient. But now that has all changed.

What’s your aim now?

The goal now is simply to diagnose the condition and then to prescribe the medications that one was taught to prescribe at medical school for that specific disease. We have outsourced our brains to the pharmaceutical industry. Without the knowledge of why this particular patient developed this particular disease at this precise time, medicine is powerless to prevent and treat disease. The modern pharmacological model makes us doctors of disease, not of health. I have no respect for doctors who dismiss the nutritional approach to disease prevention without even reading the literature. I came into medicine wanting to cure patients, but that’s not what it has now become. Sadly we have capitulated to the interests of the pharmaceutical industry, ultimately to the detriment of our and our patient’s health.

What’s your main message to the public?

Poor nutrition is the single greatest driver of chronic ill health. We’re fat because we eat too much addictive high-carbohydrate food, not because we eat too much fat and exercise too little. The food industry is committed to making profits, not to promoting health living. It doesn’t care that their addictive, highly processed foods cause heart disease, obesity, diabetes, cancer and dementia amongst many other conditions. Until we accept this, our profession can’t reverse the crippling burden of chronic ill health caused by these nutritionally-based diseases. Prescribing more drugs to treat disease caused by poor nutrition will, surprisingly, not work.

What we need is a new generation of doctors prepared to refute the dogmas they are currently being taught. And patients who demand more from my profession than the prescription of yet more drugs that are of unproven value and may even be harmful. It will take courage but it can be done. As a species it is the only way we will return to the excellent health enjoyed by humans before the growth of the processed food industry over the past 80 years.

A final word?

We humans are the only mammals that suffer from chronic ill health. One critic suggests it’s because we are the only animals clever enough to manufacture our own food – and stupid enough to eat it.

Response from Prof Frederick “Derick” Raal, head of the University of the Witwatersrand Faculty of Health Sciences, Division of Endocrinology & Metabolism:

“One’s risk for atherosclerosis, the leading cause of heart attack and stroke worldwide is related to ones “cholesterol year score’.

“If you have had a cholesterol of 5 mmol/L your whole life your arteries would have been exposed to 80 x 5 or 400 cholesterol years at the age of 80.

“If you have heterozygous familial hypercholesterolaemia ( the ‘single dose’ )your cholesterol is about twice normal ( 10 mmol/l), so when you are 40 years old your arteries would have been exposed to the same amount of cholesterol as an 80 year old with a ‘normal’ cholesterol level.

“Similarly a person with homozygous FH ( the “double dose”) who has a cholesterol of approximately 20 mmol/L will have the same exposure as an 80 year old by the age of 20.

“This is illustrated in the slide (pictured right).

“Before statins, most heterozygous FH patients died in their mid 40s or early 50s and our homozygous FH patients died before the age of 20. Statins have extended their lives considerably.

“How Tim Noakes can be so ignorant when trials in over 100,000 patients with a number of statins, plus other agents, have demonstrated reduction in mortality due to LDL-cholesterol reduction is beyond me.

Great story but as for ““How Tim Noakes can be so ignorant when trials in over 100,000 patients with a number of statins, plus other agents, have demonstrated reduction in mortality due to LDL-cholesterol reduction” is beyond me.

It is because he is “ignorant” enough not to understand how you can take incredibly small changes and blow them into absolute pronouncements. I myself am ignorant on that. My ignorance, however, extends to not understanding why, after forty or fifty years, this absolutely solid science and therapy are still debated and researchers and professionals with credentials say it is not true…and, if it were solid stuff, not one of the trials like WHI should fail, not one. But they all fail. And, as some wit on the internet put it: “The WHI created a whole new field called excuseanomics.”

Did Dr Raal refer to the study (The Efficacy of Intensive Dietary Therapy Alone or Combined with Lovastatin in Outpatients with Hypercholesterolemia published in the New England Journal of Medicine) as a smokescreen presuming no one would read it?

Or does he really not understand the results of his own reference?

The study showed that there is no net benefit to a low fat diet as LDL decreased but so did HDL, leaving no improvement in the ratio. It also showed that statins reduce LDL, however this is not in dispute. Cholesterol is in and of itself not a disease. The objective surely is to decrease CVD.

Why Dr Raal did not provide a reference to “trials in over 100,000 patients with a number of statins, plus other agents, (that) have demonstrated reduction in mortality due to LDL-cholesterol reduction” is beyond me.

To paraphrase his own quote: “He simply does not understand the difference between correlation and causation.”

Neither Tin Noakes nor Paleo diet people I have read mention Vitamin C. Humans are amongst few animals who cannot synthesize vitamin C. It is commonly found in fruit. I once spoke with Linus Pauling about it. He took about 12 grams per day in divided doses as, interms of body mass and mg/Kg, that was about how much a dog synthesized. What is the source of vitamin C in the Paleo or Banting diet. Should it not be suggested as a suplement? I personally take 1.5g twice a day. It is one of the water soluable vitamins which is not stored by the body.

It’s very possible that on a standard carbohydrate diet ( which I would suspect Linus Pauling was on) one would need a high dose of vitamin C because glucose competes with vit c to get into the cell. On a low carb, high fat diet, this is not true. If you look at where the foods with the highest amount of vit C would come from, it’s mostly fruits, which if you think about it would really be a summer food for most. I suspect that eating a LCHF or paleo diet one would not need much vitamin C.